Hygienic practice during complementary food preparation and associated factors among mothers of children aged 6–24 months in Debark town, northwest Ethiopia, 2021: An overlooked opportunity in the nutrition and health sectors

Background Hygienic practices during complementary food preparation are suboptimal in developing countries, in Ethiopia in particular. Hygienic complementary food preparation is crucial to prevent childhood communicable diseases like diarrhea and associated malnutrition among children aged 6–24 months. However, in Ethiopia, there is a paucity of evidence on the practice of hygiene during complementary food preparation. Thus, this study is aimed to assess the hygienic practice of complementary food preparation and associated factors among women having children aged 6–24 months in Debark town, northwest Ethiopia. Methods A community-based cross-sectional study was conducted among 423 mothers with 6–24 months of age children from December 1 to January 30, 2021. A simple random sampling technique was used to select the study participants. Data were collected using an interviewer-administered structured questionnaire. Epi-data version 4.6 and SPSS version 23 software were used for data entry and analysis, respectively. Binary logistic regressions (Bivariable and multivariable) were performed to identify statistically significant variables. Adjusted odds ratio with 95% CI was used to declare statistically significant variables on the basis of p-value < 0.05 in the multivariable logistic regression model. Results The study revealed that 44.9% (95% CI (40.2, 49.4%)) of the mothers having children aged 6–24 months had good practice of complementary food preparation. Maternal age of 25–29 years[AOR:3.23, 95% CI: (1.555–9.031)], husband’s attained secondary school and above (AOR:2.65, 95% CI (1.211–5.783)], using modern stove for cooking [AOR:3.33,95% CI (1.404–7.874)], having a separate kitchen[AOR: 8.59, 95%Cl: (2.084–35.376], and having a three bowl dishwashing system(AOR: 8.45, 95% CL: (4.444–16.053)) were significantly associated with good hygiene practice of complementary food preparation. Conclusions The findings have indicated that the majority of the mothers had poor hygienic practices of complementary food preparation. Mother’s age, husband’s educational status, type of stove used for cooking, having a separate kitchen, having a three bowl dishwashing system were factors that significantly influenced the hygiene practice of mothers during complementary food preparation. Therefore, training and counseling mothers and caregivers on complementary food processing and preparation is important and such endeavors which inform the development and implementation of complementary food hygiene interventions in urban communities are recommended.


Conclusions
The findings have indicated that the majority of the mothers had poor hygienic practices of complementary food preparation. Mother's age, husband's educational status, type of stove used for cooking, having a separate kitchen, having a three bowl dishwashing system were factors that significantly influenced the hygiene practice of mothers during complementary food preparation. Therefore, training and counseling mothers and caregivers on complementary food processing and preparation is important and such endeavors which inform the development and implementation of complementary food hygiene interventions in urban communities are recommended.

Background
The World Health Organization (WHO) defines Complementary Feeding(CF) as a process that starts when breast milk alone is no longer sufficient food and liquid to meet the nutritional requirements of the infant [1,2]. Guidelines of infant and young child feeding indicators recommended that complementary feeding should start after 6 months of age with continued breastfeeding up to 24 months or beyond in normal conditions and it should be hygienically prepared, stored, and fed with clean hands using clean utensils, but not bottles and teats [3,4]. This period is a transition from exclusive breastfeeding to family foods. Besides, it is a very critical time in which poor hygienic practice in preparing CF for many young children is predominant which in turn contributes significantly to the high prevalence of gastrointestinal and respiratory illnesses amongst infants [5]. Gastrointestinal diseases associated with preventable food-borne bacteria inflicting children less than two years of age remain a global health challenge [6]. Poor hygienic practices during CF preparation for infants and children play a major role in the occurrence of childhood diarrheal diseases [7]. Studies have shown that diarrheal incidence increases at the age when complementary foods are usually introduced as unhygienic preparation and handling of foods can be a source of diarrheal pathogens [8][9][10]. Diarrhea is obviously associated with malabsorption of significant nutrients, fluid losses and reduced appetite [11] which results in severe childhood nutritional problems such as wasting, and stunting [12]. Although hardware components such as improved water supplies and sanitation facilities make it easier to practice it, better hygiene still makes a huge difference in health especially in keeping children safe from infection caused by feeding of contaminated foods [13]. Improving hygiene during complementary feeding is given a special attention in the Sustainable Under nutrition Reduction in the world (SURE) program and multi-sectoral intervention are being carried out to achieve the purpose [14].
Worldwide, the lives of approximately 525,000 children are lost each year from 1.7 billion cases of different infectious diseases like childhood diarrhea with the highest mortality rates reported among children aged less than 2 years in south Asia and sub-Saharan Africa [15]. Furthermore, 230,000 children die every year globally because of diarrheal diseases associated with complementary food contaminations [3]. In African countries, data indicated that food could be more important than water in transmitting diarrheal disease, and it is estimated that 30% -40% of children aged less than 5 years suffer from different microbial pathogen diseases [5,16]. This corresponds with reports that claim that at least 70% of diarrhea-related pathogens among children are caused by contaminated complementary food [17]. Scientific evidence indicates that poor hygiene complementary feeding practices can have profound consequences on the growth, development, and survival of infants and children [16,18]. This is explained by a study conducted in Malawi which stated that 27% of 6-24 months old children were reported to have had diarrhea in the 2 weeks after initiation of CF that resulted in 80% of the children suffering from reduced height and growth rate while the rest 20% suffered from underweight [19]. Across the three studies conducted in rural India, it is shown that the prevalence of child stunting ranged from 25% to 50% [20]. According to the 2019 mini Demographic and Health Survey of Ethiopia (EDHS), current prevalence of CF is 13%, in addition to breast milk. On the other hand, infant mortality was 43% caused by preventable bacterial pathogens provoking diseases. Inadequate food hygiene is considered to be one of the major contributors to diarrhea [21]. Appropriate CF requires good hygiene while preparing complementary foods, availability of sufficient house hold-level food, and adequate nutritional knowledge application by caregivers [22]. Lack of understanding of the risk of hygiene practices of complementary feeding is the major concern in preventing and controlling food-borne diseases inflicted on 6-24 months old children in Ethiopia [23][24][25]. Improving food hygiene practices play a great role in reducing child morbidity and mortality. Previous some studies were focused on the prevalence and practice of complementary food, however, hygienic practice during complementary food preparation and some interesting variables were not addressed in Ethiopia, specifically study setting. On top of this, there is a problem in real hygiene practices of complementary feeding, resulting in serious consequences of poor child health outcomes. Therefore, the present study is aimed to assess the hygienic practice and associated factors of complementary food preparation among mothers of children aged 6-24 months in Debark town, northwest, Ethiopia.

Ethical considerations
Ethical approval was obtained from the Ethical Review Committee of Amhara Public Health Institution (APHI) with ethical letter protocol number: ref No/APHI/1499/2021 After an official letter had been submitted to Debark town health department's office, permission letters were collected/ obtained from debark town health department's office. After explaining the purpose of the study, verbal informed consent was obtained from each study participants (mothers//guardians). The respondents were also informed that they have the full right to withdraw or refuse at any time from the process. Confidentiality of information given by each respondent was kept properly and anonymity was explained clearly for the participants.

Study area
The study was conducted in Debark town, Amhara regional state, northwest Ethiopia. The town is 828 km far from Addis Ababa, the capital of Ethiopia, and about 260 kilometers from Bahir Dar city, the capital of Amhara regional state. The town has three Kebeles (the smallest administrative units of Ethiopia) and a total population of 25,350. The town has now 1 hospital, 1 health center, 2 medium clinics, 4 primary clinics, 6 pharmacies, and 2 health posts providing maternal and child health services.
Participants. The source population were all mothers were who have children aged from 6 to 24 months and resides at least six month in the debark town, while all mothers with children aged from 6 to 24 months old and who present in each kebele during the data collection period were study population.
Eligibility criteria. All selected mothers that started complementary food for children aged 6-24 months, or guardians who lived in the town for a minimum of six months during the data collection period were included. Mothers/guardians who were unable to respond, seriously ill, and unable to hear were excluded from the study.
Study variables and measurements. The outcome variable of this study was the hygienic practice in complementary food preparation, while others like socio-demographic factors, knowledge of critical time for hand washing, and environmental-related factors, knowledge and attitude of mothers towards hygiene during complementary food preparation were the explanatory variables.
The hygienic practice of complementary food preparation was assessed based on a related sixteen items questionnaire (Cronbach's alpha 0.78) and supported by observational questions which contained a three-points score scale (always, sometimes and never) and some categorical questions (yes and no),which were used for the analysis of the responses. Accordingly, the mean of the responses was computed. Participants who scored of �50% and above of the practice measuring items about hygienic complementary food preparation were labeled as having good hygienic practice and score of <50% in complementary food preparation as a poor hygienic practice [26]. Knowledge of mothers about the hygiene of complementary food preparation was assessed based on related twenty questions (Cronbach's alpha 0.73), and a threepoint score scale was used for the analysis of responses (yes always, yes sometimes, and never). Those study participants who scored mean and above mean of the sum of the knowledge questions were considered as having good knowledge [25]. Respondents were asked to respond to the 21 attitudinal questions about the hygienic practice during complementary food preparation, each question containing a 5 points likert scale (1-strongly agree, 2-agree, 3-not applicable/undecided 4-disagree and 5-strongly disagree). The responses were dichotomized as desirable and none desirable attitude, and then composited. Also, the study participants who scored mean and above mean of the attitude questions were considered as holding the desirable attitude.
Sample size determination. The sample size was determined using a single population proportion formula. Accordingly, the formula for sample size determination uses is: n = (Zα/ 2) 2 x [(p1q1)/(d) 2 ], the following assumptions were considered: n denotes the sample size, Zα/ 2 is the reliability coefficient of standard error at 5% level of significance = 1.96, p = the status of the good hygienic practice of complementary food preparation based on the 49.7% score from a previous research conducted in Woldia town, Ethiopia [27]. In that view, 10% nonresponse rate, and the final sample size approximately was 423.
The sample size was also calculated using factors associated with knowledge and practice towards hygiene by considering the following assumptions; two-sided confidence interval = 95%; power = 80%; ratio (unexposed to exposed) = 1 and 10% non-response rate (NR) ( Table 1).
Therefore, the sample size obtained by using single population formula (423) is higher than the sample size calculated by using the second objective (using factors significantly associated with outcome variable). Therefore, the minimum sample size to represent the source population was 423.
Sampling procedures. Simple random sampling technique was used to select study participants. The study participants were selected from three Kebeles using a simple random sampling technique. According to Debark town's health office report, the total number of mothers of two years old children in the study area was 10,132. The sample, 423 was drawn out from these mothers with children aged between 6 and 24 months old. The number of study participants' were allocated for each Kebele based on proportion to population size allocation methods. The list of study participants by their name and residence was found from health posts log book. Data collectors went house to house and collect the data through walk through approach randomly. When two and above mothers with 6-24 months old children were found in household, one the mother with 6-24 months old children was selected randomly.
Data collection tool and procedure. The questionnaire was developed after intensively reviewing related previous studies [29 -31]. It has three parts (socio-demographic, environmental and housing and hygiene practices). It was first prepared in English and translated to Amharic (local language) and again translated back to English by language experts (AV) S1 and S2 Annex. Data were collected by three health extension workers both in a face-to-face interview a using structured questionnaire and supported by observation under the supervision of the investigator (supervisor). The data were then checked for any incompleteness and were later coded.
Data quality management. A pre-test was done on 5% of the sample size (30 participants) in Dabat town, Keble one. A-one day training was given for the data collectors before the actual data collection. The training has covered the aim of the study, procedure, inclusion and exclusion criteria, data collection techniques, contents and details of the questionnaire, the art of interviewing and clarification. Moreover, during data collection, the supervisor has checked how the data collection process was going on. At the end of each data collection, the principal investigator also checked the completeness of the filled questionnaires. In other words, every questionnaire was checked before data entry by the principal investigator. Multicollinearity was also checked to see the linear correlation between the independent variables by using a standard error and variance inflation factor. Variables with the standard error of >2 and the variance inflation factor (VIF) from one to ten were checked by the multivariable analysis. Hosmer-Lemeshow goodness of fit test was used to check for model fitness by looking at the cut of point P-value > 0.05. The continuous variables such as age were tested using the normal curve with a histogram.
Statistical analysis. Data entry was performed using the statistical program Epi-Data version 4.6 and then exported into SPSS version 23 for analysis. Descriptive statistics were carried out and presented with narration, figure, and tabulation. Binary logistic regression (Bivariable and Multivariable) was performed to identify statistically significant variables. Variables that had P-value less than 0.25 in the binary logistic regression analysis was entered to multiple logistic regressions statistical analysis to identify independent associated factors of hygiene practice during complementary food preparation. Adjusted odds ratio with a 95% confidence interval was used to declare statistically significant variables on the basis of p-value <0.05 in the multivariable binary logistic regression model. Hosmer and Lemeshow goodness of fit test was performed and the decision was made at P>0.05.

Respondents' socio-demographic characteristics
Of the overall sample required (N = 423), all participants were included in the study; hence, the response rate was 100%. Almost all (96%) of the study participants were Amhara by ethnicity. The mean age of the respondents was (29.8±5.7sd) years. Besides, the majority of the respondents (377(89.1%) were married ( Table 2).

Environmental and housing related characteristics
Three hundred and nineteen (51.8%) of the study participants had access to information from media about hygienic complementary food preparations. In relation to the hygiene practice training, 353(83.5%) of the study participants had got food handling-related training. In the case of latrine, 363(85.8%) of the households had a latrine, of those one hundred and seventyseven (41.8%) of the participants had slaved type of pit latrine. Only 27(6.7%) of the study participants had hand washing facility with soap or detergent and sufficient water near their latrines.
More than half (223 (52.7%)) of the study participants did not wash their hands with soap after cleaning their children's buttocks. In the present study, 55.3% of the study participants had a separated three bowls dishwashing system kitchen facility ( Table 3).

Maternal knowledge and attitude towards hygienic complementary food preparation
Findings of this study showed that 274(64.8%) of the study participants had a desirable attitude towards hygienic complementary food preparation (S1 Fig).
According to knowledge status, only one hundred and eighty-one (42.8%) of the study participants had good knowledge about hygienic complementary food preparation methods. Among all study participants, the majority (376 (88.9%)) of them believed that raw and cooked complementary foods that were stored together did not lead to complementary food contamination. The study revealed that only ninety-eight (23.2%) of the respondents had unvarnished nails and 131(32.0%) did not wash their hands with water and soap before complementary food preparations ( Table 4).

Hygienic practice of complementary food preparation
The results of this study showed that the overall prevalence of good practices of complementary food preparation was found to be (44.9% 95% CI 40.2, 49.4%). Of this, participants 403 (95.7%) had utensils clean meticulously during complementary food preparation. Two hundred and seventy-two (64.3%) of the study participants washed equipments (utensils) with hot water after feeding their children (Table 5).

Factors associated with hygiene practice of complementary food preparation
The association between all potential independent variables and hygienic practice during complementary food preparation was analyzed using binary logistic regression. Accordingly, in the bivariable binary logistic regression analysis, predictor variables such as age, both maternal and husbands' educational status, occupational status, annually income, knowledge and attitude towards complementary food preparation, household source of water, access to media, having a type of latrine, presence of hand wash facility near their latrine, mothers who cleaned their baby buttock after deification, type of stove used for cooking, having separated kitchen and three bowls for complementary food preparations were explored to significantly influenced the hygienic practice mothers during complementary food preparation. After controlling for confounders in a multivariable binary logistic regression analysis, age, husband's educational status, having a modern type of stove, having a separate kitchen and having three bowls dishwashing system remained to significantly influence the hygienic practice of complementary food preparation among mothers. Hence, the odds of having good hygienic practice of complementary food preparation among mothers in the age group of 25-29 years old were Table 3

Variables
Frequency (

Discussion
This study assessed the hygienic practice of complementary food preparation among mothers with children aged 6-24 months and was living in Debark town. Similarly, the study showed that the overall prevalence of good hygienic practice of complementary food preparation among mothers was 44.9% (95% CI (40.2, 49.4%)). This finding is nearly higher than previous studies conducted in different regions of Ethiopia: Harar(39.6%) [32] and Bahir Dar (38.9%) [28]. This difference could be due to the study setting, for the previous study was conducted amongst both rural and urban communities; as a result, women might have less access to information about hygienic practice and that might have helped them to have hygienic practice of complementary food preparation [28,32]. The other reason might be the difference in terms of prevalence of food hygiene practice training. In this study,83.5% of the mothers have taken complementary food related trainings which is higher than that of the study conducted in Harar, where 20.6% of the mothers had food handling trainings [32]. However, this figure is lower than the studies conducted in Sudan (52.1%) [33], Abobo district, Ethiopia (65%) [34], and Dangila, Ethiopia (52.5%) [35]. These observed discrepancy might be due to not only the awareness, and level of knowledge about the hygiene in terms of complementary food preparation practice among mothers but also be due to the socio-demographic characteristics and the number of sample size variations. The differences in the practice of hygienic complementary food preparation among mothers or caregivers might be because of the differences in socioeconomic status, level of health services which means that health care providers provide details on how to prepare complementary food during postnatal follow up [33]. There was a difference complementary food preparation rates were inflated when compared to the observed data [36]. In terms of living standard among the study settings and the tools used for assessing hand washing practice. For example, the method used in the current study made use of self- reported practice supported by an observation whereas the studies carried out in Sudan [33] and Abobo district, Ethiopia [34]. Findings of the research conducted in the town of Dangila, Ethiopia were based on food handler mothers who had only worked in food and drink establishments' area. Accordingly, the practice of hygienic complementary food preparation was overestimated [35] and self-reported hygienic.
The current study showed that the age group of 25-29 years, education status of secondary and above of husbands, having a modern type of stove, having a kitchen separated from the main house and having a three bowls dishwashing system for 6-24 months children's complementary food preparation tools had statistically significant association with good hygienic practice of complementary food preparation. The odds of performing good hygienic practice among mothers who were in the age group of 25-29 years were 3.23 times higher as compared to those whose age group is �35 years [AOR:3.23,95% CI(1.555-9.031)]. Findings reported in a research conducted in Kerala [37] also showed that mothers aged >25 years old were better performers. The possible reason might be loss of experience in complementary food preparation as the age of the mother increases. Health education is given on hygiene, feeding and  . In other previous studies, mothers having a separate kitchen were identified as a significant factor which stated mothers who have separate kitchens might have protected complementary food from contaminated pathogens and that makes safe food for under two years old children so that these all help them keep good complementary food preparation practice [40,41]. This could be an understanding of good food hygiene handling practice with the availability of separate kitchen room safety packages.

Limitations of the study
The study acknowledged some important possible limitations that should be considered when interpreting the results. First, the study was cross-sectional, a design that does not permit establishing cause-effect relationships. Second, social desirability and recall bias might be introduced.

Conclusions
Our findings have indicated that hygienic practice of complementary food preparation among mothers with 6-24 months old children was poor. Age of women, partners' educational status, having a modern type of stove, having a separated kitchen, and having a three bowls (utensils) system for complementary food preparation were factors, which significantly influenced the hygienic practice of complementary food preparation among women with children who were 6-24 months old. Therefore, it is crucial to address the problem under study with multidisciplinary strategies targeting on health education such as complementary food hygiene and safety and treatment of drinking water along value chain. Specifically, mothers or caregivers should wash their hands before preparing and feeding the complementary food for 6-24 months of age children, and a household should have a clean kitchen room separated from main house. Mothers should also have a three bowl dishwashing system for hygiene of complementary food preparation utensils. Thoroughly reheating any cooked, stored food before serving to children and washing hands with soap before serving cooked foods and feeding the children are also recommended.